Diet Extensions & Spreadsheet Clarification

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Theodora Freeman
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1 Diet Extensions & Spreadsheet Clarification Based on a variety of diet orders related to residents that are endentulous; have difficulties chewing and/or swallowing and/or having dx: dysphagia...it has been determined that a clarification of textures and consistencies would benefit the IDT including speech (ST); dietary (CDM); dietician (RD); and activities & dietary staff by establishing a clear understanding of allowable foods by: Regular = No restrictions Mechanically altered Level I being PUREED Level II being GROUND MEATS &GRAVY SOFT TENDER VEGGIES ¼ INCH OR LESS Level III being CHOPPED & TENDER MEATS SOFT & TENDER VEGGIES ½ INCH OR LESS Level IV being REGULAR MEATS & VEGGIES These guidelines shall be used for all foods served for menu meals from the dietary department including current and future spreadsheets for present and upcoming menus. Director of Nutritional Svs. (CDM) Speech Therapist (ST) Dietician (RD) Director of Nursing (DON) Medical Director (MD) Administrator (ED)

2 Allowances & Diet Liberalization Information CMS Individualized Care training videos made the following statement: Research shows that quality of life may be enhanced by a liberalized diet ; facilities should review existing diets to minimize unnecessary restrictions ; There is a broad based consensus that dietary restrictions, the so-called therapeutic diets such as low fat, sodium restricted and modified textures diets are only sometimes helpful and may actually inhibit adequate nutrition... Generally weight stabilization and adequate nutrition are promoted by serving residents regular or minimally restricted diets. According to the Academy of Nutrition & Dietetics: Liberalized diets are defined by efforts to relax dietary prescriptions established to help manage or treat a disease like diabetes, high blood pressure, congestive heart failure, or renal disease. More than just supporting improved quality of life, a move toward liberalized diets has been shown to result in improved intake and a decrease in the malnutrition and unintended weight loss that often occurs when residents are served food they don t want and consequently won t eat. As diets are liberalized, there is opportunity for experienced dietitians, dietary managers, chefs, and nurses to educate long- and short-term residents on making wise nutritional choices, and helping them understand how their decisions, good or bad, may affect their overall health. Rights of Resident Preference for therapeutic diet: Revision of F 325 Guidelines states: Provides a therapeutic diet that takes into account the resident's clinical condition, and preferences, when there is a nutritional indication. To promote this concept; the suggested diet orders for residents approved for this program

3 will have diet orders that read: Instead of: Use: Sodium Restricted Regular/limit high sodium & no salt pkt Heart Healthy/Cardiac Regular/limit high fat foods & no salt pkt Bland Diet Regular/avoid spicy food; caffeine; pepper High Fiber Regular/increase fiber Lactose Controlled Diet Regular/limit dairy products Diabetic/Calorie Controlled Regular/limit carbs & sugary desserts Textures: Level 1 = Pureed diet Level 2= Soft vegetables; breads; ground meats Level 3 = Foods that are chopped Level 4 = Regular as prepared Liquids: Thin = as prepared Nectar=such as tomato juice; buttermilk; pre-thickened juices; milk or coffee Honey=such as honey thick; pre-thickened from vendor ie: juices; milk; coffee Pudding=thickened to a pudding like consistency Reviewed & Approved by: Director Nutritional Services Registered Dietician Medical Director Director of Nursing Neighborhood Unit Manager Administrator/ED

4 Allowances & Diet Liberalization Information CMS Individualized Care training videos made the following statement: Research shows that quality of life may be enhanced by a liberalized diet ; facilities should review existing diets to minimize unnecessary restrictions ; There is a broad based consensus that dietary restrictions, the so-called therapeutic diets such as low fat, sodium restricted and modified textures diets are only sometimes helpful and may actually inhibit adequate nutrition... Generally weight stabilization and adequate nutrition are promoted by serving residents regular or minimally restricted diets. According to the Academy of Nutrition & Dietetics: Liberalized diets are defined by efforts to relax dietary prescriptions established to help manage or treat a disease like diabetes, high blood pressure, congestive heart failure, or renal disease. More than just supporting improved quality of life, a move toward liberalized diets has been shown to result in improved intake and a decrease in the malnutrition and unintended weight loss that often occurs when residents are served food they don t want and consequently won t eat. As diets are liberalized, there is opportunity for experienced dietitians, dietary managers, chefs, and nurses to educate long- and short-term residents on making wise nutritional choices, and helping them understand how their decisions, good or bad, may affect their overall health. Rights of Resident Preference for therapeutic diet: Revision of F 325 Guidelines states: Provides a therapeutic diet that takes into account the resident's clinical condition, and preferences, when there is a nutritional indication. To promote this concept; the suggested diet orders for residents approved for this program

5 will have diet orders that read: Instead of: Use: Sodium Restricted Regular/limit high sodium & no salt pkt Heart Healthy/Cardiac Regular/limit high fat foods & no salt pkt Bland Diet Regular/avoid spicy food; caffeine; pepper High Fiber Regular/increase fiber Lactose Controlled Diet Regular/limit dairy products Diabetic/Calorie Controlled Regular/limit carbs & sugary desserts Textures: Level 1 = Pureed diet Level 2= Soft vegetables; breads; ground meats Level 3 = Foods that are chopped Level 4 = Regular as prepared Liquids: Thin = as prepared Nectar=such as tomato juice; buttermilk; pre-thickened juices; milk or coffee Honey=such as honey thick; pre-thickened from vendor ie: juices; milk; coffee Pudding=thickened to a pudding like consistency Reviewed & Approved by: Director Nutritional Services Registered Dietician Medical Director Director of Nursing Neighborhood Unit Manager Administrator/ED

6 Action Plans for Dining Program Roll Out Resident Satisfaction Tasks: Person Responsible Goal/Timeline: Update Food Preferences Accommodate all reasonable resident requests for preference CDM/Dining Supervisor/Staff Second quarter (Mission accomplished and on going) and taste within dietary restrictions Chairs/Tables in D.R. CDM/DR Supervisor/Staff CDM/Production Mgr/Chefs/Staff Initiated and on going Adm/CDM, DRM, Supervisors Menu Chat Meetings Liberalize diets/update policies for dining room monitoring Food Committee conducted monthly by CDM for the purpose of reviewing the menu and allowing for resident feedback Have all parties sign off on new policy for liberalizing diets. Install pull cord/alert buttons in dining room/in service staff CDM/Designee NSD/ED/DON/RD/Medical Director Adm/Maintenance/CDM (Chairs replaced 4/2016) Initiated and on going (Well received and choices incorporated in next week s meal planning) 1 st quarter (prior to start date) Discussion; appropriate wording; presentation; signatures; in service nursing and dietary. (Completed) Front of House: Tasks: Person Responsible: Goal/Timeline: Training Program Monthly In services. Complete Safe Serve training for staff CDM/set up with trainer for current new staff & potential new hires 3rd quarter 2015 (2 attendees passed) Standardized China Pattern Capital request submitted for new budget to standardize china pattern CDM/Administrator submitted for capital budgeted expense Uniforms: Daily Special Event Only Napkin/Tablecloth Calendar Wrap Silverware Different Colors Tablecloth Food cart(s) presenting food in dining areas (dining room; continental; and skilled hall) Cooks to be outfitted in Chef Coats; add cobbler aprons to uniforms of dietary aides/servers in dining room Routine daily foods or colors CDM/Production Mgr Changing of linens for each meal with appropriate color exchange Second quarter 2015, use excess dishes. Next year will budget for new dishes. (on going 2016) Chef coats and cobbler aprons ordered (Done) Are using difference colored tablecloth. Have posted menu items; always available items; Chef's Daily Choice NSD/Production Mgr/Chef Initiated and on going (well received and expected as part of daily routine) Update Comment Cards Presentation; choices; temperatures NSD/CDM/designee Using Food Committee Meeting

7 Minutes Back of House: Tasks: Person Responsible: Goal/Timeline: Sanitation/Safe Food Handling Implement Crandall sanitation check DSD/Production Mgr/RD/Dietary Implemented and on going per SNF list Staff guidelines and survey process Update menus: Review and Implement with Menu Manager Format DSD/Production Mgr (upcoming quarterly Crandall visit) On going Selective menus include Menu Manager format/always Available Options and Resident Choice Menu items (on going) Marinating Program Marinating program in place when DSD/Production Mgr Implemented (on going) appropriate Fresh Approach Program DSD/Production Mgr Implemented and on going Bakery Program Proofing cabinet placed in capital budget. Currently self rising on top of steam tables CDM/DSD/Production Mgr 4th quarter obtain cabinet (Done) 2 nd quarter (2016) fully implemented Garnish Program Garnish appropriate to entrée items DSD/Production Mgr/Staff On going using sauces, veggies & fruit Monitoring Process N/A N/A N/A Continental Breakfast Revamp Rotating Menu/Recipes For Consistency N/A N/A (Specialty, fruit, and cereals' bread item, all available for individual early bird/therapy/skilled unit). Update Uniforms Start of line pre shift meeting include a Uniform check All Dietary Staff (Pending) to ensure good presentation and fine dining programs Production Meeting Daily Production Meetings Daily Production Mgr On going (printed with menu) Recipes Menus & Recipes available ea. Meal DSD/Production Mgr/Menu Management Recipe Program Production Check List Provided for each day and printed DSD/Production Mgr from Menu Management Program for Chef All HACCP Forms Provided appropriate for each recipe Hot/Cold foods DSD/Production Mgr On going (printed with menu) On going (printed with menu) On going (printed with recipes)

8 Dessert Menu/Choices Menu item + fruit + Ice Cream DSD/Production Mgr On going Always Available Menu/Choices Available DSD/Production Mgr On going SNP fortified foods Available Daily DSD/Production Mgr Initiated and on going every day Create Accent Dessert/Muffin/ Identify accent items and DSD/Production Mgr Second quarter (not yet) Cookie/Cake Eliminate Run Outs 24 to 48 Hour Prep on Hand incorporate into production Prep on Hand hours Appropriate to menu items Pull Prep Prepare Hold Cook Serve DSD/Production Mgr On going Forms: Tasks: Person Responsible: Goal/Timeline: Closing & Opening Check Lists To ensure department is opened DSD/Production Mgr and closed correctly Planning stages appropriate to facility. Management Log Talking Points In services & training tidbits DSD/Production Mgr On going (shared from NSD;p seminars, ANFP articles; etc) Attendance Trackers Sign in sheets DSD/Production Mgr On going Cleaning Schedules Daily/Weekly/Monthly DSD/Production Mgr On going Revenue: Tasks: Person Responsible: Goal/Timeline: Monthly Spend down Monitor food; supplies; supplement Administrator/CDM On going cost Guest Trays Marketing Events Dining Program Action Plans for Brand Roll Out

9 DINING PROCESS The dietary department wants to thank everyone for the valuable input and feedback on the new dining process. Our residents are having more choices; hot foods; wonderful aroma; and feed more of a home style dining atmosphere; are just a few of the many comments we have received. It is not only the dietary department employees that are responsible for these changes. The team approach is the determining factor that makes it all work. Thank you for your participation. On another note.just for everyone to be on the same page..complimentary foods are available for the staff to help themselves from the hot bar in the dining room AFTER independent residents are served. To know when foods are available; the dietary staff member serving; will: have completed service removed the glass plates; bowls; and real silverware pulled juices; milks; yogurt; and UN-opened products removed the serving cart used as a counter for tray tickets/silverware and napkins back to the kitchen. In other words; complimentary foods are left-over extras we are happy to share after each of the regular meal services are complete. Thanks again, Jen, Yolanda and the Dietary Team

10 DINING PROGRAM BREAKFAST CONTINENTAL CART 100 HALL 6:45 CONCIERGE ROOM SERVICE 7:45 INDEPENDENT DINING ROOM 7:30 9:00 A.M 2ND DINING RESTORATIVE/ASSIST 8:15 A.M. ROOM HALL CARTS :50 8:15 8:45 LUNCH CONCIERGE ROOM SERVICE 11:45 INDEPENDENT DINING ROOM 11:30 1:00 P.M 2ND DINING RESTORATIVE/ASSIST 12:15 P.M. ROOM HALL CARTS :50 12:15 12:45 DINNER CONCIERGE ROOM SERVICE 4:45 INDEPENDENT DINING ROOM 4:30 6:00 P.M 2ND DINING RESTORATIVE/ASSIST 5:15 P.M. ROOM HALL CARTS :50 5:15 5:45

11 ACHIEVEMENT GOALS IMPROVE RESIDENT & FAMILY SATISFACTION *MONITOR PERFORMANCE IMPROVE OBJECTIVE *ACTION PLAN WHAT CUSTOMER EXPECTS RED LIGHT INTERNAL MARKETING *SELLING UPGRADE PERSPECTIVE BASIC PERFORMANCE STATUS QUO EXPECTED I will walk-it; talk-it; lead by example! Someone is always watching... Bless these feet where they may walk; mouth where it talks; hands and what they touch; eyes to see; heart to hold; thanks to God I am bold!

12 Food Service; Safety & Distribution ROOM SERVICE POLICIES & PROCEDURES 1. Food shall be transported in a manner that maintains safe food temperatures and prevents any source of contamination by being properly covered. 2. Food Cart(s) shall be positioned to ensure no blocking of corridors; exits; emergency equipment or patient/resident room doorways. 3. Mobile cart shall be plugged into electrical outlet to maintain consistent temperatures without use of extension cords or impeding flow of travel. 4. Food temperatures shall be taken and recorded: when initially placing prepared food(s) in mobile transport cart(s) upon delivery to service area if not in main kitchen or main dining room mid-way through service if over 20 minutes for delivery of all residents in dining area or hallways from mobile serving equipment. Upon removal of empty food pans and re-loading of new item prior to serving Only trained dietetic service personnel shall be allowed to portion out/plate foods for patient/residents. Up-to-date Diet Summary Sheet & Tray Tickets; shall remain with mobile food transport cart to ensure compliance with physician diet orders; restrictions; allergies; and preferences are available. Any patient/resident requesting or being offered foods from the room service menu must meet criteria for being offered; choosing; and receiving food is said manner in lieu of receiving a hall tray or eating in main dining room. Criteria includes: physician approval of program for said patient/resident with least restrictive diet orders in the skilled/rehab neighborhood unit; able to communicate or make needs/choices known; be willing to choose from designated menu choices available and offered; foods may be requested by therapy for patient/resident as a trial tray; and not be on isolation precautions. A hand washing sink (portable or free-standing shall be accessible in mobile food

13 service area (hall; corridor; or dining room). Water (temp min 100 degrees unless state requirements differ; soap dispenser; & single-use towels) must be available. Disposable gloves shall be worn to eliminate direct handling of foods. Policy for hand washing after removal of soiled gloves and before donning new gloves shall apply. Only trained nursing personnel or therapy staff are to assist any residents needing care for positioning prior to meal service. Reminder: Adequate supervision by a supervising nurse does not necessarily mean constant visual contact or being physically present during the meal/snack time. The assistant in the dining area(s) must be aware of and know how to access the supervisory nurse immediately in the event that an emergency should occur. Should an emergency arise, staff personnel must immediately call a supervisory nurse for help according to facility alert system. A 3 sided-enclosed busing cart will be available for dirty and/or soiled dishes; silverware; and garbage during the hours of meal service in the corridor/hallway. Separate bag will be available for any soiled clothing protectors; cloth napkins and linens that should go directly to laundry designated areas following meal service. Mobile food cart will be emptied; cleaned; and stored between designated meal service times after completion of each meal or food related activity. Allowances & Diet Liberalization Information CMS Individualized Care training videos made the following statement: Research shows that quality of life may be enhanced by a liberalized diet ; facilities should review existing diets to minimize unnecessary restrictions ; There is a broad based consensus that dietary restrictions, the so-called therapeutic diets such as low fat, sodium restricted and modified textures diets are only sometimes helpful and may actually inhibit adequate nutrition... Generally weight stabilization and adequate nutrition are promoted by serving residents regular or minimally restricted diets. According to the Academy of Nutrition & Dietetics: Liberalized diets are defined by efforts to relax dietary prescriptions established to help manage or treat a disease like diabetes, high blood pressure, congestive heart failure, or renal disease. More than just supporting improved quality of life, a move toward liberalized diets has been shown to result in improved intake and a decrease in the malnutrition and unintended weight

14 loss that often occurs when residents are served food they don t want and consequently won t eat. As diets are liberalized, there is opportunity for experienced dietitians, dietary managers, chefs, and nurses to educate long- and short-term residents on making wise nutritional choices, and helping them understand how their decisions, good or bad, may affect their overall health. Rights of Resident Preference for therapeutic diet: Revision of F 325 Guidelines states: Provides a therapeutic diet that takes into account the resident's clinical condition, and preferences, when there is a nutritional indication. To promote this concept; the suggested diet orders for residents approved for this program will have diet orders that read: Instead of: Use: Sodium Restricted Regular/limit high sodium & no salt pkt Heart Healthy/Cardiac Regular/limit high fat foods & no salt pkt Bland Diet Regular/avoid spicy food; caffeine; pepper High Fiber Regular/increase fiber Lactose Controlled Diet Regular/limit dairy products Diabetic/Calorie Controlled Regular/limit carbs & sugary desserts Textures: Level 1 = Pureed diet Level 2= Soft vegetables; breads; ground meats Level 3 = Foods that are chopped Level 4 = Regular as prepared Liquids: Thin = as prepared Nectar=such as tomato juice; buttermilk; pre-thickened juices; milk or coffee Honey=such as honey thick; pre-thickened from vendor ie: juices; milk; coffee Pudding=thickened to a pudding like consistency Reviewed & Approved by: Director Nutritional Services Registered Dietician Medical Director Director of Nursing

15 Neighborhood Unit Manager Administrator/ED

16 TENDER TOUCH BY GRACE Every resident deserves respect and regards for their quality of life. Many times progress in care can depend on the combined effort of all disciplines in any health care setting. Residents coming into Grace Healthcare of Clarksville for a skilled and rehab to home setting are here usually for a short period of time. Quality of care and their response to this care can be a determining factor of their satisfaction with the services we provide as a combined team approach. Some residents will be potentially repeat clientele for the facility as a resident or for outpatient therapy services. Making a decision to return to Grace Healthcare may depend on the care and overall perception of the united caring approach of the entire Grace team. Other residents and their friends and family may refer others based on this experience. The Tender Touch program allows an extra step in the desired satisfaction outcome for these residents. The program came about as a result of residents voicing dis-satisfaction with one area of care to representatives of another department. Instead of referring the concern to someone else with the possible perception of passing the buck for the resident; a genuine caring approach and a listening ear can correct a problem with a tender touch or basically; the right attitude. Residents should be greeted with a smile and not in a rushed pop in-out or forced appearance by a qualified and caring representative. A genuine quick visit will allow residents to give you factual information. This information may be their positive comments about their room; meals, therapy progress; and room comfort. Other comments may be voicing a level of pain; needing assistance with toileting; or needing to speak with someone in social services; housekeeping; or the business office. Hopefully not; but, it could be that someone has treated them badly. Allowing the resident or family member to know someone is readily available and engaged in their overall well-being will make their stay a positive experience under the present circumstances. This is not one of those fake it till you make it negative processes. Key elements of the tender touch program are: Knock-announce-greet the resident and/or family member with a smile! Show empathy and support for their current situation; Ask key questions and not generic open-ended ones (never ask how are you and jump on to another question); Find something positive to open the conversation (appearance; view; outfit, etc) Questions may be Are you having a good day or How was your meal to start; depending on the time of day of the visit. Ask if the room is okay; is everyone treating you well; and do you need anything? Make notes to notify other departments if concerns can not be addressed by you. Assure them you will see what YOU can do about any issues or concerns. Leave on a positive note and ensure resident satisfaction whenever possible. Ask occasionally; not every visit... Is there anything we as a team can do better? Finally, check back and follow-up on concerns...to not do this will only emphasis neglect and a non-caring attitude that will take away from any positive feelings. When discharge time is approaching; ask if the situation arises in the future if they would come back or refer someone to Grace Healthcare of Clarksville. You should be able to anticipate the answer if you truly gave a tender touch!

PEAK 2.0 SAMPLE ACTION PLAN FOOD ACTION PLAN

PEAK 2.0 SAMPLE ACTION PLAN FOOD ACTION PLAN Facility Name: Example 5 Nursing Home Domain: #1 Resident Choice Core: #1 Food ACTION PLAN Provider Number: Action Plan Contact: Phone number and/or e-mail: WHAT HAS BEEN WORKED ON IN THIS CORE AREA SINCE